Junior doctors in the NHS are taking part in a fourth strike in their long running contract dispute.

The 48 hour strike started at 08:00 this morning as the doctors prepare legal challenges to the government’s decision to impose changes to their pay and conditions from this summer.

Doctors are again providing emergency cover- but 5,000 operations and procedures have been postponed.

The latest action means the total number of treatments that have been delayed has now hit 24,500 during the dispute.

The Patients Association has come out in support of junior doctors despite the disruption, saying the government should not be imposing the contract.

But despite pleas from them and other organisations for both sides to get back round the negotiating table, the government and British Medical Association (BMA) have remained adamant they will not budge from their positions.

The BMA said it had been left with “no choice” in its fight against the government’s plan to impose a new contract in which, it said, the profession had “no confidence”.

Ministers have said the changes, which will see doctors paid less for working weekends while basic pay is increased, are needed to improve care at weekends. This is disputed by the BMA.

How the Junior Doctors dispute reached stalemate

Talks at conciliation service ACAS broke down in January

A final take-it-or-leave it offer was made by the government in February but was rejected by the BMA

Ministers subsequently announced the contract would be imposed in the summer

It will reduce the amount paid for weekend work, but basic pay is being increased

The BMA wants a more generous weekend pay allowance and more investment for more seven-day services –

the government is not increasing the overall budget for junior doctors’ pay

Two legal challenges are being pursued by doctors against the imposition

Hospitals are pushing ahead with the new contract – offers are expected to go out in May

The government is refusing to reopen talks, arguing it made compromises earlier in the year but the BMA did not

Over the past few weeks, a host of organisations, including patient group National Voices and the Academy of Medical Royal Colleges, have come forward to call on the government to drop the imposition and the BMA to stop the strikes and reopen talks.

As the latest strike got under way, Patients Association chief executive Katherine Murphy said the imposition was “not at all helpful”.

“Junior doctors are the backbone of the NHS and it is vital that they are able to provide the safe and effective care that patients need. Such a highly trained and valuable part of the NHS should not be disregarded so lightly.

“At a time when financing the NHS is already at breaking point, we should not further risk losing more doctors whose training is funded by the public purse.”

BMA junior doctors’ leader Johann Malawana said: “By pursuing its current course, the government risks alienating a generation of doctors.

“If it continues to ignore junior doctors’ concerns, at a time when their morale is already at rock bottom, doctors may vote with their feet which will clearly affect the long-term future of the NHS and the care it provides.

“Responsibility for industrial action now lies entirely with the government. They must start listening and resume negotiations on a properly funded junior doctors’ contract to protect the future of patient care and the NHS.”

Health Direct notes that when the Patients still back the Doctors, the politicians should reflect on their own dogmatic intransigence and get back to the negotiating table.

Hospitals may end be over crowded tonight as they fail to discharge patients because of the junior doctor strike.

The NHS seemed to cope well on Wednesday following the walkout from 08:00 GMT over the contract dispute. But NHS England said the second day of the 48 hour walkout in England was always going to be more difficult.

Officials said hospitals may struggle to discharge patients without junior medics on wards.

Dr Anne Rainsberry, who is in charge of planning during the strike, suggested hospitals might find it difficult to discharge patients, which could then create a backlog in hospital wards.

She said this was because they had a “valuable role” in chasing up test results and ensuring patients were ready for discharge.

“So far the NHS is holding up, but we always expected the second half of the strike will be more challenging,” she said.

She also urged patients to go to hospital only when absolutely necessary.

“If people need medical help and it’s not an emergency they should consider NHS Choices, visit their local pharmacy, or call their GP or NHS 111 for more serious matters. If their condition is an emergency or life-threatening they should call 999 as usual or go to A&E.”

Doctors are providing emergency cover during the walkout, which ends on Friday morning, and consultants, nurses and midwives are all working in hospital as normal. GP surgeries are largely unaffected.

On Wednesday just over half of junior doctors expected in work did not turn up – a figure broadly in line with the previous strikes and to be expected considering the numbers needed to provide emergency care.

The latest walkout is the third in the long running dispute, but the first to last 48 hours.

So far 19,000 operations and treatments have had to be postponed because of industrial action. The NHS carries out about 30,000 procedures a day.

Thousands of check-ups, appointments and tests have been affected as well.

Katherine Murphy, of the Patients Association, said she had “growing concern” about the dispute.

“Whatever the rights and wrongs of the arguments put forward by either side, the failure to resolve the differences by agreement is bad for doctors, bad for the taxpayer, but above all bad for patients and the NHS.”

This week’s walkout is the first of three 48 hour stoppages planned by the British Medical Association as it continues its fight against the government’s plans to force through the changes to pay and conditions. The next two are planned for April.

The union has also said it will be launching a legal challenge to oppose the imposition of the contract that was announced following last month’s strike.

But ministers have said they will be pushing ahead with imposition regardless. The new contracts are due to go out in May and will come into force from August.

The BMA said it “deeply regretted” the disruption that was being caused, but the action was necessary because of the “unfair” changes being imposed on the profession.

More than two thirds of NHS trusts and health boards are struggling to recruit qualified healthcare professionals.

Data from a BBC Freedom of Information request shows that on 1 December 2015, the NHS in England, Wales and Northern Ireland had more than 23,443 nursing vacancies – equivalent to 9% of the workforce.

In comparison, the average vacancy rate across the UK economy from November to January 2016 was 2.7%, according to the Office for National Statistics.

The figures – which include 106 out of 166 trusts and health boards in England, Wales and Northern Ireland – also revealed:

Between 2013 and 2015, there has been a 50% increase in nursing vacancies, from 12,513 to 18,714.

For doctors, the number of vacancies went from 2,907 to 4,669 – an increase of roughly 60%.

In England and Wales, there were 1,265 vacancies for registered nurses in emergency departments – about 11% of the total.

For consultants in emergency medicine there were 243 vacancies – again 11% of the total.

Paediatric consultants – specialists in the care of babies, children and young people – were also hard to recruit, with 221 vacancies – about 7% of the total.

There are many reasons for the large number of vacancies in nursing and doctor posts on hospitals in England, Wales and Northern Ireland. One simple reason is that more posts now exist, but the number of trainees has not kept up.

In the wake of the 2008 financial crash, nursing places were cut, although they are now on the way back up. The BMA suggests it takes around 15 years between a medical student starting out at university and becoming a consultant so planning the NHS workforce supply and demand is a complicated process with a long lead-in time.

But there are also increasing pressures on the health service right across the UK which the NHS is having to respond to – a growing population that is older and sicker, with more complex health needs. In plain language “complex health needs” means more than one thing going on at a time, so an elderly person might be having to cope with arthritis, diabetes and heart problems.

But one other important factor is the “Francis effect” – the report by Sir Robert Francis into the scandal at Stafford Hospital identified a shortage of nurses as a key factor in the poor care of patients. Trusts in England in particular have been under pressure to recruit more staff. But when there is a shortage of qualified nurses they have resorted to expensive agency staff and that in turn has led to a growing financial crisis.

One solution to the staff shortage adopted by many trusts is employing doctors and nurses from overseas.

The figures show 69% – of all NHS trusts and health boards are seeking staff overseas.

And in just England and Wales, the figure is nearly three quarters of all trusts and health boards – 74%.

Meanwhile, the Royal College of Nursing and the British Medical Association blame poor workforce planning for the problems hospitals are having in finding qualified staff.

Janet Davies, chief executive of the Royal College of Nursing, said: “Nursing posts are often the first target when savings need to be made, leading the NHS to find itself dangerously short and having to spend more on agency staff and recruitment from other countries.”

A spokesman for the doctor’s union the BMA – which is currently locked in a dispute with the government in England over a new contract for junior doctors – said: “Poor workforce planning means we aren’t producing enough doctors and sending them to the right areas,” he said.

Over 1,000 NHS patients have suffered from medical mistakes so serious they should never have happened.

The so called never events included the case of a man who had a whole testicle removed rather than just a cyst. In another, a woman’s fallopian tubes were taken out instead of her appendix.

Other “never events” included the wrong legs, eyes or knees being operated on and hundreds of cases of foreign objects such as scalpels being left inside bodies after operations.

Whilst NHS England insisted that such events were rare- the Patients Association said that they were a “disgrace”.

The research by the Press Association analysis also found that patients’ lives were put in danger when feeding tubes were put into their lungs instead of their stomachs.

Patients were given the wrong type of blood during transfusions and others were given the wrong drugs or doses of drugs.

The analysis showed there were:

254 never events from April 2015 to the end of December 2015

306 never events from April 2014 to March 2015

338 never events from April 2013 to March 2014

290 never events from April 2012 to March 2013

Katherine Murphy, chief executive of the Patients Association, said: “It is a disgrace that such supposed ‘never’ incidents are still so prevalent.

“How are such basic, avoidable mistakes still happening? There is clearly a lack of learning in the NHS. It is especially unforgivable to operate on the wrong organ, and many such mistakes can never be rectified.”

NHS England insisted never events were rare – affecting one in every 20,000 procedures – and that the majority of the 4.6 million hospital operations each year were safe.

A spokeswoman said: “One never event is too many and we mustn’t underestimate the effect on the patients concerned.

“To better understand the reasons why, in 2013 we commissioned a taskforce to investigate, leading to a new set of national standards being published last year specifically to support doctors, nurses and hospitals to prevent these mistakes.

More than 400 people have suffered due to “wrong site surgery”, while more than 420 have also had “foreign objects” left inside them after operations – including gauzes, swabs, drill guides, scalpel blades and needles.

Others have been given the wrong type of implant or joint replacement, some patients have been mixed up with others, and some patients have been given the wrong type of blood during a transfusion.

Some patients have also been given far too high doses of drugs, including oral methotrexate, which is used for the treatment of severe arthritis, psoriasis and leukaemia.

Health Direct notes that the vast majority of the 4.6 million hospital operations each year are safe- but if a plane crashed after every 20,000 flights then people might stop flying.

Fewer patients die after emergency surgery in hospitals that have more doctors and nurses.

The research, published in the British Journal of Anaesthesia, analysed data involving nearly 295,000 patients.

The findings stood despite patients at these hospitals being sicker and suffering more complications.

Researchers also found death was more likely following a weekend admission, which they said showed staffing was factor in the so called weekend effect.

That is the term given to the on going debate about Saturday and Sunday services.

Ministers in England are looking to improve staffing levels on the weekend, citing previous research as the basis for their policy.

Higher rates of death following weekend admissions and among babies born at weekends have been identified in two papers published by the British Medical Journal since the summer.

While this study confirms what would be expected – better resourced hospitals provide better care – it is this link with weekend care that has sparked interest.

The St George’s University of London team looked at what factors were behind variation in death rates following emergency abdominal surgery at 156 NHS trusts between 2005 and 2010.

This included surgery on ulcers, to remove appendixes and repair hernias.

While only a small number died within 30 days – just over 12,000 patients – there were small but significant variations in the death rates between those hospitals with the highest level of staffing and those with the lowest.

The third of hospitals with the lowest number of doctors per bed had death rates 7% higher than the third with the most. The difference was the same for nurse staffing levels.

Weekend admissions for emergency surgery led to an 11% increased risk in death compared with weekdays.

Lead researcher Dr Peter Holt said it was likely there would be a number of factors behind the higher death rates at weekends, but “clearly” staffing was one. “We need to ensure the whole system is safe seven days a week,” he said.

But he added the government needed to focus on getting emergency care right before even thinking about non-urgent services.

Royal College of Nursing general secretary Janet Davies said the study highlighted the importance of supporting “hard-working” staff.

“The NHS could reduce its staff turnover and save on the cost of temporary staff if it valued and invested in its permanent staff,” she said. “The benefits for all – staff, patients, and the NHS itself would be immeasurable.”

Health Direct praises hard working doctors and nurses in the NHS- but points out the current discussions on junior doctors is just one aspect of increased effectiveness- 7 day week diagnostics and consultants also needs to be addressed.

Figures from the General Medical Council (GMC) show that in the three-year period to 2013, locums working in the acute sector were attracting almost twice as many complaints as staff doctors.

That amounted to more than 250 locums being complained about with the majority of those complaints result in a formal investigation.

“I do not want to demonise locums,” the GMC’s chief executive Niall Dickson said. “Lots of good doctors are doing lots of good locum work.”

But “locum work does attract risk,” he added. “It is risky in the sense that the doctor may not know enough about the hospital where he or she is working.

“It is risky in the sense that they may be brought in when the team is under considerable pressure, and it is risky in the sense that there may be some locum doctors who find it more difficult to find a permanent job. So it is an area where we have some concerns.”

Many locums are employed through medical recruitment agencies. It’s a fast-paced business where staff have to be found – sometimes at short notice – to cover for absences and busy periods.

The GMC says employers have to do more to verify the qualifications and competence of the locums they take on. In the summer, a court case highlighted concerns that some NHS trusts and agencies were not doing the most basic pre-employment checks.

Levon Mkhitarian was jailed for six years after impersonating a doctor. He’d worked as a locum in A&E departments, cardiology and cancer wards across south London and Kent for almost two years before finally being caught.

He used a false passport and other forged documents to assume a legitimate doctor’s identity. The recruitment agency that placed him in work failed to inspect the original documents – relying instead on photocopies, which masked the fact that had “cut and pasted” them together.

It’s estimated he dealt with more than 3,000 patients – although there was no evidence that he had harmed anyone.

Mkhitarian – who had a medical degree but had failed to complete his practical training – was eventually caught when a hospital security check revealed another doctor with the same details.

Mkhitarian had a history of using deception to get locum work. Back in 2010, he obtained provisional registration with the GMC, which allowed him to work with very close supervision.

He applied, and got, locum work requiring doctors with full registration – and that went on for three years because no-one was doing the simple check on his registration status.

When the GMC discovered he had lied about his registration, he was struck off. At that point, he stole a legitimate doctor’s identity.

For Mr Dickson, the Mkhitarian case stands as a stark reminder to vet doctors before they get on to the wards.

“If someone turns up brandishing a GMC number – that does not mean they’re fit to practice,” he said.

“A GMC stamp is not good enough for anyone to say, ‘Oh, that’s alright – I don’t need to do anything.’ There are responsibilities that agencies, and responsibilities that employers, have.”

The regulator has now introduced a system of revalidation – requiring the performance of all doctors, including locums, to be regularly assessed.

The Department for Health said: “We want the NHS to be the safest healthcare system in the world and we expect all employers to carry out appropriate pre-employment checks to make sure their doctors are fit to provide safe patient care.”

Foreign patients could be charged for emergency treatment under new government plans for the NHS in England.

Visitors from outside the European Economic Area already pay for planned hospital care. The EEA covers the European Union, Iceland, Liechtenstein and Norway.

Health Secretary Jeremy Hunt wants to save the NHS millions of pounds by extending the charges to A&E care. A consultation is expected to be set up in the next few weeks.

Overseas visitors can currently receive A&E treatment, ambulance services and GP visits free of charge, but if the plans go ahead some treatment could be withheld until fees are paid.

The Department of Health said exemptions would be put in place for refugees and asylum seekers, and pregnant women would not be turned away from maternity units if they had not paid upfront.

A department spokesman said: “International visitors are welcome to use the NHS, provided they pay for it – just as families living in the UK do through their taxes.”

“This government was the first to introduce tough measures to clamp down on migrants accessing NHS care and have always been clear we want to look at extending charges for non-EEA migrants.”

“No-one will be denied urgent treatment and vulnerable groups will continue to be exempt from charging.”

All visitors to the UK and British expats are charged 150% of the cost of non-emergency NHS treatment in order to discourage people travelling to the UK just to use health services – so-called “health tourism”.

The latest crackdown is expected to reclaim around £500 million.

A spokesman for the Royal College of Emergency Medicine told the newspaper that A&E doctors “cannot reasonably be expected to take on the burden of identifying who is eligible for free treatment, and who should be charged”.

The British Medical Association agreed, saying: “A doctor’s duty is to treat the patient in front of them, not to act as border guard. Any plans to charge migrants and short-term visitors need to be practical, economic and efficient.”

In April new rules came into force which mean non-EU citizens settling in the UK for longer than six months are required to pay a “health surcharge” as part of their visa applications.

End of life care in the UK has been ranked as the best in the world with a study praising the quality and availability of services.

The study of 80 countries said thanks to the NHS and hospice movement the care provided was “second to none”.

Rich nations tended to perform the best – with Australia and New Zealand ranked second and third respectively.

But the report by the Economist Intelligence Unit praised progress made in some of the poorest countries.

For example Mongolia – ranked 28th – has invested in hospice facilities, while Uganda – 35th – has managed to improve access to pain control through a public-private partnership.

The rankings were worked out following assessments for the quality of the hospitals and hospice environments, staffing numbers and skills, affordability of care and quality of care.

Just 34 out of 80 countries provided what could be classed as good end-of-life care – and these accounted for just 15% of the adult population.

The report said the quality of end-of-life care was becoming increasingly important with the ageing population, meaning people were increasingly facing “drawn-out” deaths.

It’s no major surprise that richer countries, with stronger health systems, provide some of the world’s best palliative care. But a few poorer nations are bucking the trend, and it’s often down to the efforts of individuals campaigning for everyone to be allowed a dignified and pain-free death. Panama, Chile, Mongolia and Uganda are singled out for praise, whereas the situation in India and China is described as “worrying”.

India ranked 67th in the index, and China was in the bottom 10 at 71. Both have huge populations and have experienced rapid economic growth, but care for people at the end of their lives has not kept up. The report warns further improvements are needed across all countries to cope with the future demands of an aging population, increasingly facing drawn-out illnesses such as cancer, heart disease and dementia.

The UK received top marks for affordability – as would be expected for a service that is provided free at the point of need – but also got a perfect score for quality of care.

Overall it was given 93.9 out of 100, but the report still said there was room for improvement – as there was with all the top-performing nations.

Services in England have recently been criticised by the Parliamentary and Health Service Ombudsman.

The UK also came top the last time this report was produced in 2010. Also in the top 10 this time were the Irish Republic, France, Germany and the US.

Iraq and Bangladesh finished bottom of the ranking, while China was in the worst 10.

Health Secretary Jeremy Hunt said the UK lagged behind other western European countries in cancer survival rates and the new measures would help “close the gap”.

“We know that the biggest single factor that means that our cancer survival rates lag those of France, Germany and other European countries is the fact that we have too much late diagnosis; we don’t get an answer to people quickly enough,” he said.

Mr Hunt said he was making “a very simple promise to all NHS patients” that by 2020 they would have a cancer diagnosis or an all-clear within 28 days.

However, the Department of Health later clarified that while it hoped to achieve the Independent Cancer Taskforce target of 95% by 2020, it would only be clear once trials were completed whether that was achievable.

Currently 280,000 people in England are diagnosed with cancer each year – with half surviving for at least 10 years.

Patients are meant to see a specialist within two weeks of a GP referral under existing targets but may then face a long wait for test results, meaning a growing number of patients do not get their treatment started within the recommended 62 days.

Cancer patients will also get online access to their test results if they choose, under the new measures.

Harpal Kumar, chief executive of Cancer Research UK and chairman of the Independent Cancer Taskforce, said services for diagnosing cancer were under immense pressure, which is why increased investment and extra staff were so important.

“Introducing the 28-day ambition for patients to receive a diagnosis will maximise the impact of this investment which, together with making results available online, will spare people unnecessary added anxiety and help cancer patients to begin treatment sooner,” he said.

The announcement comes after a cross-party group of MPs warned that cancer services had “lost momentum” in the past two years.

The health service has been struggling to meet waiting times and seen resources reduced, the Public Accounts Committee warned.

A row over spending on mental health in England has broken out after Labour accused the government of failing to honour promises to boost funding.

Freedom of information requests made by Labour to NHS commissioning bodies in England suggest on average mental health budgets fell in 2015-16.

However, the Department of Health said it rejected the figures and called mental health a government “priority”.

Guidance from NHS England published in December 2014 said funding in 2015-16 should increase “by at least as much” as the increase in overall allocation.

It is part of a wider goal laid out in the NHS five-year plan to put mental health on a par with physical health.

Dr Phil Moore, chairman of the NHS Clinical Commissioners Mental Health Commissioners Network stressed that CCGs understood the importance of investing in mental health, but financial pressures may leave no room for increased spend in any one area.

He said commissioners were also looking into different ways of funding mental health including using the voluntary sector and more community schemes.

“It is important to note that many CCGs are not simply looking to invest more in the same models of care that have failed in the past.”

The figures collected by Labour suggest that 50 of the 130 CCGs who responded plan to reduce the proportion of the budget they allocate to mental health for this financial year.

On average the figures suggest that in 2015/16 CCGs are planning to allocate 10% of their budgets to mental health, compared with 11% in 2014/15. But NHS England said CCGs would spend 13% of their budgets on mental health this year.

Labour also said there was wide variation between what CCGs had set aside for mental health.

Shadow public health minister Luciana Berger said ministers had repeatedly promised that the amount spent on mental health locally would increase in line with local CCG budgets.

A Department of Health spokesperson said: “We do not recognise these figures – NHS England has shown mental health spending has increased by £400 million this year.

“Mental health is a priority for this government and to say otherwise ignores the fact we have given mental and physical health conditions equal priority in law, we’ve increased central funding by millions of pounds, and introduced the first ever treatment targets which will make sure funding goes to where it’s needed.”